Van Horn II, John •
NEW YORK STATE DEPARTMENT OF HEALTH �1.1
Vital Records Section .. Burial - Transit Permit
Name First Middle • Last Sex
John G. Van Horn II
Ili Date of Death Age If Veteran of U.S. Armed Forces,
06 / 01 / 2018 61 War or Dates
} Place of Death Hospital, Institution or
' City, Town or Village Stillwater Street Address 576 Route 9P
g Manner of Death Natural CauseitQ Accident D Homicide E Suicide 7 Undetermined �Pending
Circumstances Investigation
Medical Certifier Name Title
Howard Schlossberg MD
Address
3 Crossing Blvd, Clifton Park, NY 12065
Death Certificate Filed District Number Register Number
City,Town or Village Stillwater
iil'i; Date Cemetery or Crematory
06 / 04 / 2018
Entombment Pine View Crematory
Address
`''E.Cremation Queensbury, NY
Date Place Removed
�Removal and/or Held
and/or Address
Hold
m. Date Point of
Q Transportation Shipment
by Common Destination
Carrier
•
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IGL'
` ::' Permission is hereby granted to dispose of the human remai descri above as' dicated.
Date Issued le-q-JoiF Registrar of Vital Statistics ‘d,
(si re)
<; District Number 4/6-6 7 Place Stillwater , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Ip+(, ll6 Place of Disposition Z, /r.'r.io._.ess)
•
K M (section) (1t number) r (grave number)
Name of Sexton or Person in Charge o Premises . (A _ **
(plea print) •
Signature PR Nit- Title fRT� 1tVL
•
(over)
DOH-1555 (02/2004)